Universal Confusion

Since when is Republican health care "universal"?

The Republican alternative "budget"unveiled Thursday is getting ridiculed for what it lacks: numbers of any kind. But there's plenty to mock that's actually in the budget, too. Take the phrase "universal access to affordable health care," which the document uses no fewer than seven times.

Since when do Republicans use the word universal to describe their health care policies? And what—if not government-sponsored, single-payer, socialist health coverage—do they mean by it?

The formulation is not especially new—for either party. In 1992, then-presidential candidate Bill Clinton promised "guaranteed universal access" to health care. Gov. Bobby Jindal used the phrase in his response to President Obama's speech to Congress in February: "We stand for universal access to affordable health care coverage. What we oppose is universal government-run health care." Republican Sen. Bob Bennett of Utah likewise tried to tease apart the "universal" from the "single-payer" at a policy breakfast in early March: "Republicans are coming to the understanding that their opposition to universal coverage is misplaced. ... Let's understand that when we say we cover everybody ... that is not a step toward a single-payer government-run system."

Still unclear? The budget itself supports "leveling the playing field" through "tax incentives." It proposes letting individuals shop for health plans across state lines and praises state-based solutions rather than national ones. And a spokeswoman for the House Republican Conference, asked whether it's possible to have universal access without a mandate, said: "Yes, by making health care universally affordable and leveling the tax code to give all taxpayers incentives to purchase it."

To review: GOP officials aren't exactly helpful. The document itself is scant on details (although, to be fair, more may emerge next week when the bill is voted on). And the spokeswoman simply rearranges the text of the document. So what, exactly, does the phrase "universal access to affordable health care" mean?

Let's give it a shot. The difference between the Republican "universal" and the Democratic "universal" is clearly in the word access. Under a Democratic universal health care plan, everyone is covered whether they like it or not. That can be enforced with an individual mandate—forcing people to buy insurance—or a tax levied on people who don't. Under a Republican plan, "universal access" means anyone can buy insurance if they want it, but they don't have to.

The problem is, "access" is a slippery concept. George W. Bush famously said that "people have access to health care in America. After all, you just go to an emergency room." By that definition, "universal access" already exists. (Unfortunately, that doesn't solve the "affordable" part. Emergency room visits cost a lot more for uninsured patients than for their would-be insurers.) In other cases, access means being able to visit a doctor who will accept your insurance policy. For example, 7 million people in California are enrolled in the state's Medi-Cal program, but more than half of the doctors don't accept the card. So even if you're technically covered, it doesn't mean you have access. Other times, there simply aren't enough doctors to go around.

But even that is not necessarily what Republicans mean by "access." More likely, they're suggesting that anyone who can't afford health care will be eligible for a tax credit—say, $5,000 a year—that will enable them to buy into an individualized plan. (That's not unlike John McCain's plan, except McCain would have eliminated tax incentives for employer-based health care.) You don't have to take advantage of the tax credit. In fact, many wouldn't. According to modeling by the RAND Corp., only 15 million of the 45 million uninsured Americans would become insured under such a plan. (That assumes that everyone who makes less than $100,000 is eligible.) So it probably wouldn't result in universal coverage, but it would allow them to claim that the plan offers universal access.

Even if the tax credit were high enough that everyone could afford coverage, access would still not be "universal." Insurers could continue to deny coverage for pre-existing conditions. (Currently, five states require insurers to cover people no matter what.) Some patients would still struggle to find doctors who accept their coverage. Nor would it shrink the long waiting lists for those denied coverage to enter high-risk pools.

Policy aside, shoehorning the word universal into the GOP's health care pitch has the whiff of rebranding. Polls show that most Americans favor health care for all. Sixty-five percent of Americans think the government should "guarantee" health care. In 2003, a Washington Post poll found that 62 percent of Americans preferred universal health care to the current system. Even more than half of Republicanssay that universal health coverage should be the right of every American, according to one poll.

Emphasizing "universal access" also lets the GOP sound equally ambitious while quietly reframing the debate. "By setting the bar at access, they're trying to define the problem in a way that the solution is something minor rather than something major," says Anthony Wright of Health Access California.

March 3 2015 1:39 PMThe “Most Pleasurable Portrayal of Libertarianism“ Bonus SegmentDavid, Emily, and John discuss what Parks and Recreation got right about government.Emily Bazelon, David Plotz, and John Dickerson